1530 Scrimshaw, N S, Taylor, C E, and Gordon, J E, Interactions of Nutrition and Infection, WHO Monograph No 57. Geneva, World Health Organisation, 1968. 6 Heatley, R V, Williams, R H P, and Lewis, M H, Postgraduate Medical Journal, 1979, 55, 541. 6 Moghissi, K, et al, British Journal of Surgery, 1977, 64, 125. 7Murray, M J, et al, British Medical_Journal, 1978, 2, 1113. 8 Fielding, L P, Stewart-Brown, S, and Dudley, H A F, Lancet, 1978, 2, 778.

The undiscovered country For believers and unbelievers alike, man's survival in some form after death is no problem. The believer has his unshakable certainties-diversified in a variety of religions. The unbeliever's certainty rests on the lack of any scientifically acceptable evidence that activity of the human mind survives death of the brain. So doubts about the possibility of some form of life after death remain to puzzle only the sceptics and the agnostics. These, particularly if trained in the ways of science, are far from happy with "evidence" from spiritualism and mediums and from accounts of ghosts and apparitions. (Lack of confidence in these paranormal experiences does not necessarily throw doubt on the rather better evidence of equally inexplicable phenomena such as thought transference and extrasensory perception, but psychic interchanges between living people are irrelevant to the question of survival.) Thus the parascientific areas are not yet entirely respec-table; for example, Dr Eugene Brody felt obliged to defend his editorial decision in 1977 to devote a whole issue of his journal' to the paranormal, reincarnation, and the evidence of man's survival after death. One of his contributors on that occasion-Ian Stevenson- has recently, with a colleague,2 examined a narrower issue. What conclusions, if any, can justifiably be drawn from near-death experiences ? The material they surveyed includes accounts from people falling in climbing accidents who expected to die but escaped,3 experiences recorded from people after cardiac arrest4-6 and other near-fatal illnesses,3 7 8 and the stories of the rare people who have survived suicidal jumps9 from the Golden Gate bridge, San Francisco (the world's favourite starting-point for a suicidal leap, with 535 suicides since it opened in 1937). Stevenson and Greyson2 were able to identify some common features, which agreed with the rather sparse reports of others who have studied similar material. Most of these survivors commented on the increased speed of thought that they experienced and on the slowing and expansion of time. They agreed, too, on an absence of fear and on a calmness and tranquillity of mind. Many gave accounts of panoramic memory and a review of previous life-the traditional experience of the drowning man. The exceptions were survivors from the Golden Gate bridge, none of whom had experienced any form of panoramic memory. The absence of this sensation in these would-be suicides may have been connected with the lack of unexpectedness, so characteristic of both the mountaineering and the cardiac-arrest groups. Moreover, several of those who jumped were psychotic or at least mentally abnormal. Another experience frequently mentioned was autoscopyseeing oneself lying or standing apart from oneself as a spectator. Some writers on autoscopy compare it to the doppelganger experience,10 11 which is seen by one author as a

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denial of death.12 Hackett et a15 reported denial of death but not autoscopy in 20 out of 50 survivors of coronary infarction. Depersonalisation-feeling the self to be unreal-is another frequent consequence of a near-death experience.3 7 This is difficult to understand, because the feeling-tone in the classic description of depersonalisation13 is most unpleasant, whereas descriptions of near-death emphasise sensations of calmness and serenity. Most of those who have been near death have also described some kind of mystical or transcendental experience-heavenly colours, visions, a conviction of having "entered an unearthly realm," or an impression of

rebirth. The striking agreement in the reports from people in different countries and cultures and in different decades encourages the belief that valid conclusions could be drawn from them; but Stevenson and Greyson2 are nevertheless right in advocating caution. Suggestion on the part of the interviewer (whether enthusiastic or sceptical), subtle communication from other survivors, and published and broadcast accounts of others' experiences may all play a part in exaggerating any apparent conformity in survivors' accounts. More important, these accounts are-by definition-neardeath experiences and depend, so far as we know, on a functioning and not a dead brain. Noyes14 reminds us that ''no one has returned from the dead and given an account of his experiences." Death remains, in Hamlet's words, "The undiscover'd country from whose bourn/No traveller returns...." The near-dead are not dead; and the dead, whether surviving in some form or not, can be left to thanatology and eschatology.

'Brody, E B, Journal of Nervous and Mental Disease, 1977, 165, 151.

Stevenson, I, and Greyson, B,J7ournal of the American Medical Association, 1979, 242, 265. 3 Noyes, R, and Kletti, R, Psychiatry, 1976, 39, 19. 4 Druss, R G, and Kornfeld, D S, Journal of the American Medical Association, 1967, 201, 291. 5 Hackett, T P, Cassem, N H, and Wishnie, H A, New England Journal of Medicine, 1968, 279, 1365. 'Dobson, M, et al, British Medical3Journal, 1971, 3, 207. Noyes, R, et al, Journal of Nervous and Mental Disease, 1977, 164, 401. 8 Sabom, M B, and Kreutziger, S,J7ournal of the Florida Medical Association, 1977, 64, 648. 9 Rosen, D H, Western Journal of Medicine, 1975, 122, 289. 1 Lukianowicz, N, Archives of Neurology and Psychiatry, 1958, 80, 199. 11 Trethowan, W H, in Current Themes in Psychiatry 2, ed R N Gaind and B L Hudson, p 317. London, Macmillan, 1979. 12 Ehrenwald, J, J'ournal of Nervous and Mental Disease, 1974, 159, 227. 13 Ackner, B, Journal of Mental Science, 1954, 100, 838. 14 Noyes, R, Psychiatry, 1972, 25, 174. 2

Palindromic rheumatism Hippocrates has been quoted as a precedent' for the use of "palindromic" to signify a recurring condition. In theory it could be applied, say, to angioneurotic oedema or proctalgia fugax. In medical practice nowadays the term is practically confined to "palindromic rheumatism," a rare disorder with a relatively short history. First described by Hench and Rosenberg in 1944,2 palindromic rheumatism is characterised by repeated attacks of pain in or near joints and lasting from hours to days. The bouts subside completely without residual disability. Men and women are equaliy susceptible. The hands and wrists seem to be especially frequently and severely affected; and pain, redness, and swelling may be striking. Inflammation of

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tissues in the vicinity of joints may be more obvious than arthritis, and sometimes median nerve entrapment gives rise to the carpal tunnel syndrome. The acute inflammatory appearance ofthe disorder makes gout and cellulitis possibilities in the differential diagnosis. The relation of palindromic rheumatism to rheumatoid arthritis has long been debated. Ropes and Bauer3 suggested in 1945 that some of the patients had rheumatoid arthritis and not palindromic rheumatism; Ward and Okihiro4 found, in a five-year follow-up study, that as many as a third of 140 patients with palindromic rheumatism developed rheumatoid arthritis; Bywaters and Ansell1 found that rheumatoid arthritis developed later in 30 of 66 patients. In each series there was wide variation in the duration of the palindromic phase-from months to many years. In two of these studies a few patients eventually developed systemic lupus erythematosus. The sedimentation rate is often raised,2 and a small proportion (though in one study5 as many as 300%') of the patients have positive tests for rheumatoid factor in the serum. This finding, together with the clinical course, led to the view in the late 1960s that palindromic rheumatism was a state that could, for unknown reasons, develop into either rheumatoid arthritis or lupus erythematosus. Now there seems to be some doubt whether palindromic rheumatism is an entity at all; the 1970 edition of Copeman's textbook had a separate section on palindromic rheumatism' but not the 1978 edition, which appears to dismiss it as an early variant of rheumatoid arthritis. Recently-and predictably in view of the surge of interest in diseases attributed to the formation and deposition of soluble immune complexes-there have been studies of serum complement components5 and of immune complexes6 in patients with palindromic rheumatism, including some who later developed rheumatoid arthritis; Patients showed no reduction in serum complement, a finding that would argue against palindromic rheumatism as predominantly an immunecomplex disease. Similarly, immune complexes were found seldom-and only in patients with positive rheumatoid factor tests. Palindromic rheumatism, then, is less a diagnosis than a label attached to a patient whose clinical state fits the description given above. The pathogenesis remains unknown. The prognosis seems to be strongly affected by the presence of rheumatoid factor in the blood; when this is present the diagnosis is probably best changed to rheumatoid arthritis. Management must rely on symptomatic treatment, for no prophylactic measures are available. The non-steroid antiinflammatory drugs, particularly indomethacin or phenylbutazone, may suffice; but pain may be severe enough to require pethidine. Corticosteroids are usually to be avoided; but periodic short courses-say, two intramuscular injections of 80 mg methylprednisolone in depot form at three-day intervals-may be strikingly effective, and the risks of side effects seem negligible provided that the treatment is not repeated too frequently. 1 Bywaters, E G L, and Ansell, B, in Textbook of the Rheumatic Diseases, 4th edn, ed W S C Copeman, p 524. Edinburgh and London, Livingstone, 1970. 2 Hench, P S, and Rosenberg, E F, Archives of Internal Medicine, 1944, 73, 293. 3 Ropes, M W, and Bauer, W, New England J7ournal of Medicine, 1945, 233, 592 and 618. 4 Ward, L E, and Okihiro, M M, AIR Archives of Interamerican Rheumatology, 1959, 2, 208. 5 Wajed, M A, Brown, D L, and Currey, H L F, Annals of the Rheumatic Diseases, 1977, 36, 56. 6 Thompson, B, et al, Annals of the Rheuimatic Diseases, 1979, 38, 329.

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Ludlow's preternatural bag In an age in which diagnosis was confined to bedside observation and diagnostic accuracy could be verified only by postmortem examination Abraham Ludlow, a Bristol surgeon, described "a case of obstructed deglutition from a preternatural dilatation of, and a bag formed in, the pharynx."' His account (in a letter to William Hunter written in 1764) was the first detailed description of the anatomy and pathophysiology of pharyngo-oesophageal diverticulum or pharyngeal pouch and antedated by 107 years Zenker's2 description of the diverticulum which bears his name. Little can be added today to Ludlow's detailed clinical and anatomical description, beautifully illustrated by Jan van Rymsdyk's drawings,3 of the postmortem specimen now in the pathological collection of Glasgow Royal Infirmary, and they form a splendid example ofthe way in which painstaking recording of symptoms and morbid anatomy can be applied to the art of clinical

investigation. Why diverticula should arise from the posterior pharyngeal wall immediately above the cricopharyngeus, which constitutes the upper oesophageal sphincter, is far from clear. Ludlow attributed it in his patient to a cherry stone lodging in the "loose holes which abound in the lower pharynx" and being forced outwards by swallowing through the anatomical weak spot, now known as Kilian's dehiscence,4 between the lower borders of the inferior pharyngeal constrictors and the upper border of the cricopharyngeus. Since pharyngeal pouches seldom appear until late middle age, they seem unlikely to result simply from a congenital weakness. Elsewhere in the alimentary tract diverticula are caused by motor incoordination causing high intraluminal pressures which force a pouch of mucosa through a weak spot in the muscle coat. This happens, for example, in oesophageal spasm and colonic diverticulosis. Originally achalasia of the cricopharyngeus was postulated to be the cause of pharyngeal pouch, but manometric studies have shown that the muscle relaxes during swallowing.5 An association does exist between pharyngeal pouch and hiatus hernia with gastro-oesophageal reflux,6 which increases the resting tone of the cricopharyngeal sphincter7-so reducing the risk of regurgitation into the mouth and respiratory tract. Even in these circumstances, however, the cricopharyngeus still relaxes adequately during swallowing. In patients with pharyngeal pouches what does seem to occur is a lack of co-ordination of the pharyngeal phase of swallowing with premature relaxation and closure of the cricopharyngeus. This has been shown both cineradiographically8 and manometrically.9 Closure of the cricopharyngeus while the pharyngeal constrictor muscles are still contracting and the oropharynx remains closed off generates transiently high pressures in the pharynx,10 which might well extrude a mucosal pouch through Kilian's dehiscence. Such premature cricopharyngeal closure is present only in about half of the recorded swallows; presumably its pathogenesis is related to degenerative changes in the nerve supply. Rational treatment for pharyngeal pouch should be based on understanding the underlying pathophysiological disorder. Small pouches may disappear after cricopharyngeal myotomy alone,'1 but this will not alleviate symptoms when a larger pouch is present. Apart from the risk of aspiration of the pouch contents into the respiratory tract, there is another hazard: carcinoma may arise in untreated pharyngeal pouches'2 and has been reported even after the Dohlman procedure of

Palindromic rheumatism.

1530 Scrimshaw, N S, Taylor, C E, and Gordon, J E, Interactions of Nutrition and Infection, WHO Monograph No 57. Geneva, World Health Organisation, 19...
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